Formula
MDF = 4.6 × (PTpatient − PTcontrol) + Bilirubinmg/dL
PT in seconds · Bilirubin in mg/dL (divide μmol/L by 17.1)
Interpretation
| MDF | Severity | 28-day Mortality (untreated) | Action |
|---|
| < 32 | Less severe | ~15–20% | Supportive treatment; nutritional support; alcohol abstinence; no steroids |
| ≥ 32 | Severe alcoholic hepatitis | ~35–50% | Consider prednisolone 40 mg/day × 28 days (if no contraindications); assess steroid response with Lille score at day 7 |
Clinical Application
Before starting steroids: Exclude active infection (spontaneous bacterial peritonitis, sepsis, pneumonia), active GI bleeding, hepatorenal syndrome not responding to treatment, and renal failure with creatinine >2.5 mg/dL. Steroid use in active untreated infection is associated with mortality.
- Diagnosis first: Maddrey DF presupposes a clinical diagnosis of alcoholic hepatitis (history of heavy alcohol use, jaundice, AST:ALT ratio >2, elevated bilirubin, raised ALP, tender hepatomegaly). Biopsy is not required to start treatment in classic presentations.
- DF ≥ 32 with prednisolone: Prednisolone 40 mg/day orally for 28 days, then taper or stop. Screen for tuberculosis and hepatitis B before steroids. NNT approximately 5 to prevent one death in severe alcoholic hepatitis.
- Lille Score (day 7 assessment): A Lille score >0.45 at day 7 of prednisolone indicates non-response and predicts high mortality — discontinue steroids to avoid immunosuppression without benefit. A Lille score ≤0.16 indicates complete response.
- NAC adjunct: N-acetylcysteine may be added to prednisolone in severe disease (AASLD 2018 recommendation, conditional; evidence from the Nguyen 2011 trial — improved 30-day but not 90-day survival).
- Nutritional support is essential: Target 35–40 kcal/kg/day with 1.5 g/kg/day protein; nasogastric tube feeding if oral intake inadequate. Nutritional support alone improves short-term survival and is not inferior to steroids in some studies.
- Alcohol abstinence: The most critical long-term intervention. MELD at 90 days after abstinence predicts recovery of hepatic function — patients who remain abstinent may not need liver transplantation.
- Early liver transplantation (without the traditional 6-month sobriety rule) for highly selected first-episode severe alcoholic hepatitis non-responders to steroids is an emerging option in specialist centres (Mathurin 2011 paradigm).
References
- Maddrey WC, et al. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology. 1978;75(2):193–199.
- Louvet A, et al. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology. 2007;45(6):1348–1354.
- Singal AK, et al. AASLD Practice Guidance in Alcohol-Associated Liver Disease. Hepatology. 2018;68(4):1553–1600.
- Thursz MR, et al. (STOPAH). Prednisolone or Pentoxifylline for Alcoholic Hepatitis. N Engl J Med. 2015;372(17):1619–1628.